|
HC SIMP REP SUP WND 7.6-12.5CM FACE
|
Facility
|
IP
|
$1,356.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
900501028
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.44 |
| Max. Negotiated Rate |
$1,017.00 |
| Rate for Payer: Adventist Health Commercial |
$271.20
|
| Rate for Payer: Cash Price |
$745.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$918.01
|
| Rate for Payer: Heritage Provider Network Senior |
$918.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$245.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$339.00
|
| Rate for Payer: Multiplan Commercial |
$1,017.00
|
|
|
HC SIMP REP SUP WND 7.6-12.5CM FACE
|
Facility
|
OP
|
$1,356.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
900501028
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$271.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$931.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$745.80
|
| Rate for Payer: Cash Price |
$745.80
|
| Rate for Payer: Cash Price |
$745.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$881.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$918.01
|
| Rate for Payer: Heritage Provider Network Senior |
$918.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$646.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$245.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$339.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$1,017.00
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$487.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$448.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC SIMP REP SUP WND GT 30.0CM
|
Facility
|
IP
|
$1,931.00
|
|
|
Service Code
|
CPT 12018
|
| Hospital Charge Code |
900501732
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$349.51 |
| Max. Negotiated Rate |
$1,448.25 |
| Rate for Payer: Adventist Health Commercial |
$386.20
|
| Rate for Payer: Cash Price |
$1,062.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,307.29
|
| Rate for Payer: Heritage Provider Network Senior |
$1,307.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$349.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$482.75
|
| Rate for Payer: Multiplan Commercial |
$1,448.25
|
|
|
HC SIMP REP SUP WND GT 30.0CM
|
Facility
|
OP
|
$1,931.00
|
|
|
Service Code
|
CPT 12018
|
| Hospital Charge Code |
900501732
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$386.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,326.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$1,062.05
|
| Rate for Payer: Cash Price |
$1,062.05
|
| Rate for Payer: Cash Price |
$1,062.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,255.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,307.29
|
| Rate for Payer: Heritage Provider Network Senior |
$1,307.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$921.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$349.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$482.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$1,448.25
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$694.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$639.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC SIMP REP SUP WND LT 2.5 CM
|
Facility
|
OP
|
$854.00
|
|
|
Service Code
|
CPT 12001
|
| Hospital Charge Code |
900501020
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$170.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$586.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$469.70
|
| Rate for Payer: Cash Price |
$469.70
|
| Rate for Payer: Cash Price |
$469.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$555.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$578.16
|
| Rate for Payer: Heritage Provider Network Senior |
$578.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$407.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$640.50
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$282.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC SIMP REP SUP WND LT 2.5 CM
|
Facility
|
IP
|
$854.00
|
|
|
Service Code
|
CPT 12001
|
| Hospital Charge Code |
900501020
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$154.57 |
| Max. Negotiated Rate |
$640.50 |
| Rate for Payer: Adventist Health Commercial |
$170.80
|
| Rate for Payer: Cash Price |
$469.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$578.16
|
| Rate for Payer: Heritage Provider Network Senior |
$578.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.50
|
| Rate for Payer: Multiplan Commercial |
$640.50
|
|
|
HC SIMP REP SUP WND LT 2.5CM FACE
|
Facility
|
OP
|
$911.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
900501025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$164.89 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$182.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$486.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$625.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$501.05
|
| Rate for Payer: Cash Price |
$501.05
|
| Rate for Payer: Cash Price |
$501.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$592.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$616.75
|
| Rate for Payer: Heritage Provider Network Senior |
$616.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$434.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$164.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$227.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$683.25
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$327.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$301.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC SIMP REP SUP WND LT 2.5CM FACE
|
Facility
|
IP
|
$911.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
900501025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$164.89 |
| Max. Negotiated Rate |
$683.25 |
| Rate for Payer: Adventist Health Commercial |
$182.20
|
| Rate for Payer: Cash Price |
$501.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$616.75
|
| Rate for Payer: Heritage Provider Network Senior |
$616.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$164.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$227.75
|
| Rate for Payer: Multiplan Commercial |
$683.25
|
|
|
HC SIMP REP SUP WND OVER 30.0 CM
|
Facility
|
OP
|
$1,524.00
|
|
|
Service Code
|
CPT 12007
|
| Hospital Charge Code |
900501024
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$304.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,046.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$252.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$990.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$277.72
|
| Rate for Payer: Dignity Health Senior |
$252.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$252.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,031.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1,031.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$252.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$726.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$275.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$290.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$318.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$318.11
|
| Rate for Payer: Multiplan Commercial |
$1,143.00
|
| Rate for Payer: Multiplan WC |
$402.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$548.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$504.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$277.72
|
| Rate for Payer: Vantage Medical Group Senior |
$252.47
|
|
|
HC SIMP REP SUP WND OVER 30.0 CM
|
Facility
|
IP
|
$1,524.00
|
|
|
Service Code
|
CPT 12007
|
| Hospital Charge Code |
900501024
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$275.84 |
| Max. Negotiated Rate |
$1,143.00 |
| Rate for Payer: Adventist Health Commercial |
$304.80
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,031.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1,031.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$275.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.00
|
| Rate for Payer: Multiplan Commercial |
$1,143.00
|
|
|
HC SIM REP SUP WND 12.6-20CM FACE
|
Facility
|
OP
|
$1,604.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
900501407
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$320.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,101.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$761.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$558.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$507.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$882.20
|
| Rate for Payer: Cash Price |
$882.20
|
| Rate for Payer: Cash Price |
$882.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,042.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$761.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$558.40
|
| Rate for Payer: Dignity Health Senior |
$507.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$507.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,085.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1,085.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$507.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$765.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$290.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$583.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$639.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$639.63
|
| Rate for Payer: Multiplan Commercial |
$1,203.00
|
| Rate for Payer: Multiplan WC |
$808.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$577.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$531.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$761.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$558.40
|
| Rate for Payer: Vantage Medical Group Senior |
$507.64
|
|
|
HC SIM REP SUP WND 12.6-20CM FACE
|
Facility
|
IP
|
$1,604.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
900501407
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$290.32 |
| Max. Negotiated Rate |
$1,203.00 |
| Rate for Payer: Adventist Health Commercial |
$320.80
|
| Rate for Payer: Cash Price |
$882.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,085.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1,085.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$290.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$401.00
|
| Rate for Payer: Multiplan Commercial |
$1,203.00
|
|
|
HC SIM REP SUP WND 20.1-30CM FACE
|
Facility
|
OP
|
$1,801.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
900501243
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$360.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,237.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$761.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$558.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$507.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,959.00
|
| Rate for Payer: Cash Price |
$990.55
|
| Rate for Payer: Cash Price |
$990.55
|
| Rate for Payer: Cash Price |
$990.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,170.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$761.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$558.40
|
| Rate for Payer: Dignity Health Senior |
$507.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$507.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,219.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1,219.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$973.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$507.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$859.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$325.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$583.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$450.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$639.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$639.63
|
| Rate for Payer: Multiplan Commercial |
$1,350.75
|
| Rate for Payer: Multiplan WC |
$808.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$648.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$596.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$761.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$558.40
|
| Rate for Payer: Vantage Medical Group Senior |
$507.64
|
|
|
HC SIM REP SUP WND 20.1-30CM FACE
|
Facility
|
IP
|
$1,801.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
900501243
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$325.98 |
| Max. Negotiated Rate |
$1,350.75 |
| Rate for Payer: Adventist Health Commercial |
$360.20
|
| Rate for Payer: Cash Price |
$990.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,219.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1,219.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$325.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$450.25
|
| Rate for Payer: Multiplan Commercial |
$1,350.75
|
|
|
HC SINOGRAM/FISTULAGRAM ABSCESS
|
Facility
|
IP
|
$1,803.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
909001858
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$326.34 |
| Max. Negotiated Rate |
$1,352.25 |
| Rate for Payer: Adventist Health Commercial |
$360.60
|
| Rate for Payer: Cash Price |
$991.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,220.63
|
| Rate for Payer: Heritage Provider Network Senior |
$1,220.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$326.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$450.75
|
| Rate for Payer: Multiplan Commercial |
$1,352.25
|
|
|
HC SINOGRAM/FISTULAGRAM ABSCESS
|
Facility
|
OP
|
$1,803.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
909001858
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$1,352.25 |
| Rate for Payer: Adventist Health Commercial |
$360.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$963.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,238.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,045.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$766.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$696.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$274.25
|
| Rate for Payer: Blue Shield of California Commercial |
$222.77
|
| Rate for Payer: Blue Shield of California EPN |
$179.14
|
| Rate for Payer: Cash Price |
$991.65
|
| Rate for Payer: Cash Price |
$991.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,171.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,045.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$766.34
|
| Rate for Payer: Dignity Health Senior |
$696.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,171.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$696.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,116.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1,116.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$67.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$696.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$860.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$326.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$801.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$450.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$877.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$877.80
|
| Rate for Payer: Multiplan Commercial |
$1,352.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$696.67
|
| Rate for Payer: TriValley Medical Group Senior |
$696.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$378.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$378.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,045.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$766.34
|
| Rate for Payer: Vantage Medical Group Senior |
$696.67
|
|
|
HC SINUS/ PARANASAL COMPLETE
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
909001141
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$155.66 |
| Max. Negotiated Rate |
$645.00 |
| Rate for Payer: Adventist Health Commercial |
$172.00
|
| Rate for Payer: Cash Price |
$473.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$582.22
|
| Rate for Payer: Heritage Provider Network Senior |
$582.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.00
|
| Rate for Payer: Multiplan Commercial |
$645.00
|
|
|
HC SINUS/ PARANASAL COMPLETE
|
Facility
|
OP
|
$860.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
909001141
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$54.03 |
| Max. Negotiated Rate |
$645.00 |
| Rate for Payer: Adventist Health Commercial |
$172.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$459.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$590.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$167.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$123.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$111.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$205.59
|
| Rate for Payer: Blue Shield of California Commercial |
$166.80
|
| Rate for Payer: Blue Shield of California EPN |
$134.13
|
| Rate for Payer: Cash Price |
$473.00
|
| Rate for Payer: Cash Price |
$473.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$559.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$167.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.07
|
| Rate for Payer: Dignity Health Senior |
$111.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$559.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$111.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$532.34
|
| Rate for Payer: Heritage Provider Network Senior |
$532.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$54.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$111.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$410.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$128.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$215.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$140.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$140.97
|
| Rate for Payer: Multiplan Commercial |
$645.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$111.88
|
| Rate for Payer: TriValley Medical Group Senior |
$111.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$167.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.07
|
| Rate for Payer: Vantage Medical Group Senior |
$111.88
|
|
|
HC SIROLIMUS
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
900912167
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$38.19 |
| Max. Negotiated Rate |
$158.25 |
| Rate for Payer: Adventist Health Commercial |
$42.20
|
| Rate for Payer: Cash Price |
$116.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$142.85
|
| Rate for Payer: Heritage Provider Network Senior |
$142.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.75
|
| Rate for Payer: Multiplan Commercial |
$158.25
|
|
|
HC SIROLIMUS
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
900912167
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$158.25 |
| Rate for Payer: Adventist Health Commercial |
$42.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$112.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$144.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.56
|
| Rate for Payer: Blue Shield of California Commercial |
$110.42
|
| Rate for Payer: Blue Shield of California EPN |
$88.57
|
| Rate for Payer: Cash Price |
$116.05
|
| Rate for Payer: Cash Price |
$116.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$137.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Senior |
$13.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.61
|
| Rate for Payer: Heritage Provider Network Senior |
$130.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$100.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.30
|
| Rate for Payer: Multiplan Commercial |
$158.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.73
|
| Rate for Payer: TriValley Medical Group Senior |
$13.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Vantage Medical Group Senior |
$13.73
|
|
|
HC S & I STENT/CHEST VERT ART EA
|
Facility
|
IP
|
$5,431.00
|
|
|
Service Code
|
CPT 0076T
|
| Hospital Charge Code |
909081391
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$983.01 |
| Max. Negotiated Rate |
$4,073.25 |
| Rate for Payer: Adventist Health Commercial |
$1,086.20
|
| Rate for Payer: Cash Price |
$2,987.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,676.79
|
| Rate for Payer: Heritage Provider Network Senior |
$3,676.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$983.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,357.75
|
| Rate for Payer: Multiplan Commercial |
$4,073.25
|
|
|
HC S & I STENT/CHEST VERT ART EA
|
Facility
|
OP
|
$5,431.00
|
|
|
Service Code
|
CPT 0076T
|
| Hospital Charge Code |
909081391
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$983.01 |
| Max. Negotiated Rate |
$12,620.00 |
| Rate for Payer: Adventist Health Commercial |
$1,086.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,731.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,616.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,987.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,073.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,680.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$2,987.05
|
| Rate for Payer: Cash Price |
$2,987.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,530.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,616.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,616.35
|
| Rate for Payer: Dignity Health Senior |
$4,616.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,258.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,361.79
|
| Rate for Payer: Heritage Provider Network Senior |
$3,361.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,590.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$983.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,357.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,801.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,801.70
|
| Rate for Payer: Multiplan Commercial |
$4,073.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,616.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,616.35
|
| Rate for Payer: Vantage Medical Group Senior |
$4,616.35
|
|
|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
OP
|
$1,215.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906820016
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$219.91 |
| Max. Negotiated Rate |
$3,620.97 |
| Rate for Payer: Adventist Health Commercial |
$243.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$649.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$834.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,032.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$668.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$911.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,620.97
|
| Rate for Payer: Blue Shield of California Commercial |
$741.15
|
| Rate for Payer: Blue Shield of California EPN |
$592.92
|
| Rate for Payer: Cash Price |
$668.25
|
| Rate for Payer: Cash Price |
$668.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$789.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,032.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,032.75
|
| Rate for Payer: Dignity Health Senior |
$1,032.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$789.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$752.09
|
| Rate for Payer: Heritage Provider Network Senior |
$752.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$528.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$579.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$219.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$303.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$850.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$850.50
|
| Rate for Payer: Multiplan Commercial |
$911.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$607.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$607.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,032.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,032.75
|
| Rate for Payer: Vantage Medical Group Senior |
$1,032.75
|
|
|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
IP
|
$1,250.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906811484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$226.25 |
| Max. Negotiated Rate |
$937.50 |
| Rate for Payer: Adventist Health Commercial |
$250.00
|
| Rate for Payer: Cash Price |
$687.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$846.25
|
| Rate for Payer: Heritage Provider Network Senior |
$846.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$312.50
|
| Rate for Payer: Multiplan Commercial |
$937.50
|
|
|
HC S&I STENT COARCT INCL LSCA
|
Facility
|
OP
|
$1,250.00
|
|
|
Service Code
|
CPT 75956
|
| Hospital Charge Code |
906811484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$226.25 |
| Max. Negotiated Rate |
$3,620.97 |
| Rate for Payer: Adventist Health Commercial |
$250.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$668.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$858.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,062.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$687.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$937.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,620.97
|
| Rate for Payer: Blue Shield of California Commercial |
$762.50
|
| Rate for Payer: Blue Shield of California EPN |
$610.00
|
| Rate for Payer: Cash Price |
$687.50
|
| Rate for Payer: Cash Price |
$687.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$812.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,062.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,062.50
|
| Rate for Payer: Dignity Health Senior |
$1,062.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$812.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$773.75
|
| Rate for Payer: Heritage Provider Network Senior |
$773.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$528.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$596.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$312.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$875.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$875.00
|
| Rate for Payer: Multiplan Commercial |
$937.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$625.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$625.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,062.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,062.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,062.50
|
|
